SOAP Note 2
SOAP NOTE:
Patient Initials: D.P. Age: 71 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): "Here for a follow up and to discuss my back."
History of Present Illness (HPI):
71 year old Caucasian fem
...
SOAP Note 2
SOAP NOTE:
Patient Initials: D.P. Age: 71 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): "Here for a follow up and to discuss my back."
History of Present Illness (HPI):
71 year old Caucasian female who presents for 6 month follow up. She has a history of
hypertension which is controlled with medication. She denies any vision changes, dizziness,
headaches, or vertigo. She reports bilateral lower back pain that has been present for
approximately 2 weeks. She reports that her pain is intermittent and is pressure like. She denies
any pain traveling down her legs. She reports that her pain is increased with activity. She reports
taking Ibuprofen occasionally with pain relief. She rates her pain at this time as a 2/10 on the
pain scale. She reports that she was seen yesterday by a chiropractor and had an adjustment. She
states that her pain is improved today. She denies any fever, chills, nausea, vomiting, pain with
urination, hematuria, foul smelling urine, urinary frequency or urgency.
She also reports concerns regarding weight gain and wishes to discuss weight loss options. She
denies any changes in her eating or exercise habits. She denies attempting a diet or exercise
regimen. She does admit to eating sweets often, and sometimes eating an entire box of "cakes" as
well as other sugary foods. She is wondering if a diet pill would be a good fit for her and is
wondering if another blood pressure medication needs to be added due to weight gain.
Medications:
Aspirin 81 mg po daily
Black Cohosh root Extract 160 mg po daily
Zyrtec 10 mg po daily
Lisinopril/HCTZ 20-12.5 mg po daily
Meloxicam 15 mg po daily
Potassium Chloride IO meq ER po daily
Zocor 10 mg po daily
Vitamin C 250 mg po daily
Vitamin B-12 1000 mcg po daily
Premarin vaginal cream
Allergies:
Codeine - anaphylaxis : severe allergy.
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